It's a small world after all

In the past few years, there has been an interesting and important trend happening in operative dentistry.

Louis Malcmacher, DDS

In the past few years, there has been an interesting and important trend happening in operative dentistry. This trend has been toward more conservative, more minimally invasive techniques that allow us to keep the preparation of teeth as small as possible. We are all aware that when you initially cut into a virgin tooth, it starts a lifelong trend of having to replace restorations that get bigger and bigger until a tooth could potentially end up with an endodontics procedure and a crown. This does not happen in all situations, but certainly is a routine part of every dental practice.

The minimally invasive thinking is that the less you need to prepare teeth for restorations, the less likely the tooth will end up with endo treatment and a crown. This is good for the patient, especially today with the many materials and techniques we have to prepare and restore teeth very conservatively. Another big plus in minimally invasive dentistry is that the less you need to prepare, the less the need for local anesthesia as well. I routinely will prepare teeth — especially on children and adolescents — with many of these techniques just because I don't have to use local anesthesia.

Air abrasion and laser technology have helped this trend. Dentists who have invested in these technologies have been at the leading edge of minimally invasive dentistry. There is a significant financial investment to get into these technologies, which is why most dentists have shied away from them and not made them a standard in every dental office. As these technologies become more standard and cost-effective, they may someday become a routine sight in every dental office.

In the meantime, there are a few low-technology ways of providing more conservative operative dentistry. First of all, wearing surgical telescopes and loupes is fast becoming the standard. There is simply no way to do minimally invasive dentistry without them. You can't treat what you can't see.

Fissureotomy carbide burs were introduced a few years ago and are a step in this direction as well. The fissureotomy burs allow you to stay within the enamel and cut tiny, minimal preps into the pits and fissures of teeth. They allow you to find out if that dark stain you see with your loupes is really a stain — or the beginning of a large, carious lesion.

Recently, a new resin-fiber-reinforced, slow-speed, polymer instrument was introduced. SmartPrep (SS White) instruments are a slow-speed solution to the dilemma that we all have of whether we are removing healthy dentin or carious dentin. SmartPrep only will remove carious dentin, which is a new advance for minimally invasive dentistry and a new advancement in operative dentistry. Many times, no local anesthesia is necessary to open up the enamel with a fissureotomy bur and then follow it with the slow-speed SmartPrep instrument. These minimal preparations can then easily be restored with self-etching bonding agents such as Tenure Unibond (Den-Mat), Xeno (Dentsply Caulk), Prompt L-Pop (3M ESPE), and the composite resin of your choice.

There have been advancements in caries detection as well. The DIAGNOdent (KaVo) is a laser-assisted caries detector that many dentists have found to be a valuable addition to their dental practices. The DIAGNOdent is certainly the first of what is going to be a new way to detect caries. In the near future, caries detection will become one of the hottest topics in dentistry with the introduction of new laser technology and fluorescence to create 3-D images of the teeth. They will not only show the depth of the caries but also the precise location, which will really help us treat patients that much better. This is an interesting area of technology, and in the near future will be responsible for creating a very exciting time for dentistry.

In dentistry, it is not "the bigger, the better," but rather "the smaller, the better" when it comes to operative dentistry. Try some of the things mentioned here and be part of these new and exciting developments. Minimally invasive dentistry will be a key concept in the way we practice dentistry for years to come.

Dr. Louis Malcmacher is an international lecturer and author known for hiscomprehensive and entertaining style.An evaluator for Clinical Research Associates, Dr. Malcmacher is a consultant to the Council on Dental Practice of the ADA. For close to two decades, Dr. Malcmacher has inspired his audiences to truly enjoy practicing dentistry by providing the knowledge necessary for excellent clinical and practice-management skills. His group dental practice has maintained a 45 percent overhead since 1988.For details about his speaking schedule, Dr. Malcmacher can be reached at (440) 892-1810 or via email at dryowza@iname.com.

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